NCLEX-PN
NCLEX Maternity Questions Questions
Extract:
Question 1 of 5
The oncoming shift nurse assesses the fundus of the postpartum client 6 hours after a vaginal birth and finds that it is firm. When the nurse then assists the client out of bed for the first time, blood begins to run down the client’s leg. Which action by the nurse in response to the client’s bleeding is correct?
Correct Answer: A
Rationale: Lochia normally pools in the vagina when the postpartum client remains in a recumbent position for any length of time. When the client then stands, gravity causes the blood to flow out. As long as the nurse knows the fundus is firm and not bleeding, a simple explanation to the client is all that is required. There is no reason to return the client to bed; the fundus is firm. There is no reason to push the emergency call light. Increased bleeding is an expected response when standing for the first time. There is no reason to call the HCP.
Question 2 of 5
The postpartum client, who had a forceps-assisted vaginal birth 4 hours ago, tells the nurse that she is having continuing perineal pain rated at 7 out of 10 and rectal pressure. An oral analgesic was given and ice applied to the perineum earlier. What should the nurse do now?
Correct Answer: B
Rationale: Reexamination of the perineum should be completed before calling the HCP to report the pain level. A forceps-assisted delivery can increase the risk of hematoma development. Rectal pressure and perineal pain can indicate a hematoma in the posterior vaginal wall. The nurse should closely examine the perineum and the vaginal introitus for ecchymosis and a bulging mass. Ambulation would not help the perineal pain. A stool softener would be appropriate to avoid constipation but would not help the immediate problem.
Question 3 of 5
Which activity should the nurse recommend to prepare for labor?
Correct Answer: A
Rationale: Practicing relaxation and breathing techniques helps manage labor pain and prepares the client for childbirth.
Question 4 of 5
The nurse advises the client to perform which exercise to strengthen pelvic floor muscles?
Correct Answer: A
Rationale: Kegel exercises strengthen pelvic floor muscles, aiding postpartum recovery and preventing incontinence.
Question 5 of 5
The nurse correctly sends a requisition and specimen for which laboratory test?
Correct Answer: C
Rationale: Human chorionic gonadotropin (hCG) is the hormone tested to confirm pregnancy, as it is produced by the placenta shortly after implantation.